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BURNETT COUNTY ZONING ADNIINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION ($50) <br /> POWTS RECONNECTION ($25) <br /> POWTS REVISION($25) <br /> Application Information—Type or Print <br /> Property Owner Name ( �(�/ Property Legal Description <br /> Jt Are S. JJ\e_tl A5e I GL 3 1/4 Zy 1A,S 2 ,T yJN,R/5-W <br /> Property Owners Mailing Or <br /> Lot Number Block Number 1L <br /> io35 Il'1i:'m,.:,- Or (.LI L'1 Z`12Zyo-: CO V� <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number V�` <br /> fir R?u,ew thv C. 1 551 Z(,� 1 (65'f l `t-7, 4or Z (2SNt V Ll P'39 YC�� <br /> Type of Building: (Check one) ❑ State-Owned ❑City learest Rad (Jt^y <br /> E[ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public rtl'fownofrAkS"q; Fire Number <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,recreation/entertainment event etc.)] <br /> r��7-�Z-z•y�-�5-2y-5 �5-�.�3 -�t�•�t�� E <br /> Type of Permit: County# Type of Non-Plumbing Device/System/Toilet/Unit: <br /> ErNon-Plumbing(Privy,Toil State# 2rivy—Pit Toilet ❑ Composting Toilet System <br /> ❑ POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device � <br /> ❑ POWTS Repair gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision ❑ Other <br /> ti <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> ❑I,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> L?r,'Ie undersigned,assume responsibility for the installation of the non-plumbing sanitary system for which this permit is issued. ra <br /> Plu(m/b�ees/Owner's Name(print) P bees/Owner's Si tare: MP/MPRS W No.: Business Phone Number. <br /> Plumber's Address(Street,City,State,Zip Cod6). <br /> 1 rne�-C,.:iv r i4. SLt 2V:e.> /1'tvv SS1Z1� <br /> Office Use Only: <br /> ❑Disapproved Permit Feer CST No. Date Issued I in at Signature <br /> Approved ❑Owner Given Initial Adverse <br /> Determination <br /> Comments: Q <br /> /n <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />